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Brian Klepper, PhD RAND Corporation recently published a report showing that, on average, private health plans (and the employers and unions that typically sponsor them) pay hospitals 241% of what Medicare pays for the same procedure or service. Of course, there’s lots of variation around that...

Al Lewis By way of background, there are two things you need to know before launching into this Valid Points article: Livongo, a venture-capital funded diabetes management company, recently published a study in the Journal of Medical Economics alleging a significant savings in diabetes-related spending for...

Brian Klepper, PhD A couple weeks ago a Journal of the American Medical Association article reported the results of a large (33,000 employees) rigorous study of worksite wellness programs. As explained in The New York Times, the research “found no significant differences in outcomes like lower blood pressure or sugar...

Fred Goldstein

Recently two articles were sent to me by Cliff Frank, a colleague and friend. If you know anything about Cliff, you’ll know that 1) if he’s sending something, it’s worth reading, and 2) he doesn’t mince words. In this case, with regard to the first article, it was one short line:

“Fascinating article about crap in our own state (Florida).”

After reading it and sending an email in which I discussed the historical basis of this behavior, my response became three short lines:

  • “Just more recycling of S.O.S.”
  • “How much good care could be provided if we got rid of this garbage.”
  • “Shaking my head.”

The Mother Jones article – “Mom, When They Look at Me, They See Dollar Signs” – was an unbelievable read about the abuses being done by substance abuse treatment centers in Florida and around the country. Well, I really shouldn’t have considered it unbelievable. In the early 90’s I got out of that industry quickly after arriving at one of a two psychiatric/substance abuse hospital system whose owners were doing some things that just weren’t ethical or possibly legal, although not to the extent of this article. The examples cited in this article were way beyond the pale:

  • Putting the people up in hotels after being discharged from the treatment center and providing them with drugs so they can then test positive and be readmitted,
  • Paying the patient for coming to the facility and while they are there, paying huge bonuses to patient recruiters, and
  • Charging exorbitant fees.

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Brian Klepper

A class action legal ruling this month, on a case originally filed in 2014, found that UnitedHealthCare’s (UHC) mental health subsidiary, United Behavioral Health (UBH), established internal policies that discriminated against patients with behavioral health or substance abuse conditions. While an appeal is expected, patients with legitimate claims were systematically denied coverage, and employer/union purchasers who had paid for coverage for their employees and their family members received diminished or no value for their investments.

Central to the plaintiff’s argument was the fact that UBH developed its own clinical guidelines and ignored generally accepted standards of care. In the 106 page ruling, Judge Joseph C. Spero of the US District Court in Northern California wrote, “In every version of the Guidelines in the class period, and at every level of care that is at issue in this case, there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.” He concluded that the emphasis was “pervasive and result[ed] in a significantly narrower scope of coverage than is consistent with generally accepted standards of care.” Judge Spero found that UBH’s cost-cutting focus “tainted the process, causing UBH to make decisions about Guidelines based as much or more on its own bottom line as on the interests of the plan members, to whom it owes a fiduciary duty.”Read More

Brian Klepper

A year ago, 92 primary care physicians (PCPs) in Charlotte, NC broke away from the region’s largest health system, Atrium Health, forming Tryon Medical Partners, an independent, physician-owned group. Then, a couple weeks ago, another 41 PCPs left the area’s second largest health system, Novant, to join Holston Medical Group, a large multispecialty physician practice with more than 80 PCPs headquartered in nearby Kingsport, TN.

In these and most primary care breakaways from large health systems, the complaints are generally the same. Within a fee-for-service, volume-driven environment, primary care’s role, at least in part, is to capture patients and feed the machine. Health systems pressure PCPs to refer patients internally as often as possible for lucrative diagnostics and procedures.Read More